Luminal and extraluminal bleeding during EUS-guided double-balloon–occluded gastrojejunostomy bypass in benign gastric outlet obstruction with portal hypertension

A 45-year-old man with longstanding idiopathic chronic pancreatitis and splenic venous thrombosis presented with postprandial vomiting and abdominal fullness 10 months earlier. He received a diagnosis of duodenal narrowing (D1-D2 junction) (Fig. 1) and underwent several sessions of endoscopic balloon dilation, with an ill-sustained response. Surgery was attempted elsewhere; however, gastrojejunostomy was not done because of extensive perigastric collaterals. His laboratory evaluation showed moderate anemia (hemoglobin 10 gm/dL), platelets 1.2 lakhs/mm3, prothrombin time 17 seconds (international normalized ratio 1.28) and normal liver function test results, serum amylase levels, and lipase levels.